Ending Nightmares Caused By PTSD

Some patients with PTSD suffer recurring nightmares of a single event.

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Originally published on January 16, 2012 4:44 am

Everyone has nightmares sometimes. But for people with PTSD, it's different.

Sam Brace doesn't want to talk about what he saw when he was a soldier in Iraq eight years ago. In fact, it's something he's actively trying not to dwell on. But what he can't control are his dreams.

They're almost always about the same explosion. "When I was overseas, we'd hit an IED," Brace says. "When I have a nightmare, normally it's something related to that."

Healthy dreams seem kind of random, according to Steven Woodward, a psychologist with the National Center for PTSD at the VA Medical Center in Menlo Park, Calif. "They're wacky," he says. "They associate lots of things that are not normally associated."

PTSD dreams are the same real-life event played over and over again like a broken record. "Replicative nightmares of traumatic events ... repeat for years," Woodward says. "Sometimes 20 years."

Scientists wanted to find out the reason why people with PTSD can't sleep and dream normally. One theory comes from Matthew Walker, a psychology researcher at the University of California, Berkeley. His particular interest lies in rapid eye movement, or REM. It's the time during sleep when a lot of dreaming occurs.

It's also a time when the chemistry of the brain actually changes. Levels of norepinephrine — a kind of adrenaline — drop out completely. REM sleep is the only time of day when this happens. That struck Walker as a mystery. "Why would rapid eye movement sleep suppress this neurochemical?" he asks. "Is there any function to that?"

Walker found that in healthy people, REM sleep is kind of like therapy. It's an adrenaline-free environment where the brain can process its memories while sort of stripping off their sharp, emotional edges. "You come back the next day, and it doesn't trigger that same visceral reaction that you had at the time of learning."

Emotions are useful, he says. They show us what really matters to us. "But I don't think it's adaptive to hold onto that emotional blanket around those memories forever," he says. "They've done their job at the time of learning, then it's time to hold on to the information of that memory, but let go of the emotion."

Walker's theory suggests that in people with PTSD, REM sleep is broken. The adrenaline doesn't go away like it's supposed to. The brain can't process tough memories, so it just cycles through them, again and again.

So, what if you could make the adrenaline just go away? Enter prazosin.

Pfizer Inc. introduced the drug under the brand name Minipress in the 1970s to treat high blood pressure. Dr. Murray Raskind, a VA psychiatrist in Seattle, says the drug, now generic, can cost anywhere between 5 and 15 cents. And, actually, it's not terribly effective as a blood pressure medication, he says.

But what prazosin does do is make people less sensitive to adrenaline. About a decade ago, Raskind starting giving prazosin to some of his PTSD patients, including one Vietnam War veteran.

"He had this recurrent nightmare of being trapped by the Vietcong forces in a landing zone and having his best friend killed in front of his eyes by a mortar round," Raskind says.

After a few weeks of treatment with prazosin, the veteran came in for a follow-up appointment. Raskind says the veteran told him that he wasn't sure the medication was working. He was still having the same dream over and over — just about something else. He told Raskind that in the new dream he was in his fifth grade classroom and there was a test. If he didn't pass the test, he wasn't going to be promoted to the next grade. But he never even got the assignment.

"I said, 'That's my nightmare!' " Raskind says.

Indeed, the veteran's new dream was the stress dream of a healthy brain trying to work things out, Raskind says.

This year, the VA is expected to finish up its trial for prazosin. It's already prescribing the drug to about 15 percent of its PTSD patients. Raskind, of course, would like to see that number rise.

Today in Your Health, we'll report on one of the effects of post-traumatic stress. One of the biggest problems people face is a simple one - getting a good night's sleep.

INSKEEP: They may be plagued by insomnia or by nightmares. From our member station KQED, Amy Standen reports on new treatments that are emerging.

AMY STANDEN, BYLINE: Sam Brace doesn't want to talk about what he saw when he was a soldier in Iraq eight years ago. In fact, it's something he's actively trying not to dwell on. But what he can't control are his dreams.

SAM BRACE: I just had one last week.

STANDEN: They're almost always about the same explosion.

BRACE: When I was overseas we had hit an IED. And when I have a nightmare, normally it's something related to that.

STANDEN: Everyone has nightmares sometimes. But in people with PTSD, it's different. Steve Woodward is a psychiatrist with the National Center for PTSD at the VA Medical Center in Menlo Park, California. He says healthy dreams seem kind of random.

DR. STEVE WOODWARD: They're wacky. They associate lots of things that are not normally associated.

STANDEN: PTSD dreams are the same real-life event played over and over again. A broken record.

WOODWARD: Replicative nightmares of traumatic events that repeat for years sometimes, 20 years.

STANDEN: So the question scientists had was why. Why can't people with PTSD sleep, and dream, normally? One theory comes from a psychology researcher at the University of California, Berkeley named Matt Walker.

What interests Walker is rapid eye movement, or REM. It's the part of sleep where a lot of dreaming occurs. But it's also a time when the chemistry of the brain actually changes. Levels of a kind of adrenaline called norepinephrine drop out completely. REM is the only time of day that this happens. And that struck Walker as a mystery.

MATT WALKER: Why would rapid eye movement sleep suppress this neurochemical? Is there any function to that?

STANDEN: Walker found that in healthy people, REM sleep is kind of like therapy - an adrenaline-free environment where the brain can process its memories while sort of stripping off their sharp, emotional edges.

WALKER: So that you come back the next day, and yes, you can better recollect it, but also it doesn't trigger that same visceral reaction that you had at the time of learning.

STANDEN: And this is a healthy thing to do, he says, because emotions are useful. They show us what really matters to us.

WALKER: But I don't think it's adaptive to hold onto that emotional blanket around those memories forever. They've done their job at the time of learning. They've told you they're important. And, then it's time to hold on to the information of that memory, but let go of the emotion. The emotion's done its job.

STANDEN: Walker's theory is that in people who have PTSD, REM sleep is broken. The adrenaline doesn't go away like it's supposed to. Their brain can't process tough memories, so it just cycles through them, again and again. So what if you could make the adrenaline go away? This brings us to a VA psychiatrist in Seattle named Murray Raskind and a drug called prazosin.

DR. MURRAY RASKIND: Prazosin was introduced in 1973 by Pfizer Pharmaceuticals to treat high blood pressure.

STANDEN: Prazosin has one main side effect, which is dizziness. It's also cheap.

RASKIND: Costs anywhere from 5 to 15 cents.

STANDEN: And actually, it's not terribly effective as a blood pressure medication. But what prazosin does do is make people less sensitive to adrenaline. About a decade ago, Raskind starting giving prazosin to some of his PTSD patients, including one Vietnam vet.

RASKIND: He had this recurrent nightmare of being trapped by the Vietcong forces in a landing zone and having his best friend killed in front of his eyes by a mortar round.

STANDEN: After a few weeks of prazosin, the man came in for a follow-up appointment.

RASKIND: And he said, I don't know, Doc. I'm not sure this stuff's working.

STANDEN: I'm still having the same dream over and over, he said, just about something else.

RASKIND: Now I'm in my fifth-grade classroom. And there's a test. And if I don't pass this test, I'm not going to be promoted to the next grade. And I never even got the assignment.

STANDEN: It was the stress dream, says Raskind, of a healthy brain, trying to work things out.

RASKIND: And I said, That's my nightmare.

STANDEN: This year, the VA is expected to finish up its trial for prazosin. It's already prescribing the drug to about 15 percent of its PTSD patients. Raskind, of course, would like to see that number rise.

RASKIND: To us it's a simple thing that works.

STANDEN: Works, that is, at giving at least some people who have experienced something terrible a shot at a normal night's sleep.